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Original article
Does the change in the immunization dosing schedule of 10-valent pneumococcal conjugate vaccine has any impact among children in the northwest of Sao Paulo, Brazil?
¿El cambio de las dosis en el calendario de inmunización de la vacuna conjugada antineumocócica 10-valente tiene algún impacto entre los niños del noroeste de São Paulo, Brasil?
R.P.-D.l. Ossaa,
Corresponding author
rolapater@usp.br

Corresponding author.
, R.G. Siebena, M.C. Cervia, D.A.F.d.S. Limab, R. Santosa, D.C. Aragona
a Pediatric Department, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
b Microbiology Laboratory, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Streptococcus pneumoniae</span> &#40;<span class="elsevierStyleItalic">S&#46; pneumoniae</span>&#41; is responsible for non-invasive and invasive pneumococcal disease &#40;IPD&#41; principally in children under 5 years old&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">In Brazil&#44; the introduction of pneumococcal conjugate vaccine&#44; in the National Immunization Program &#40;PNI&#41;&#44; happened through the 10-valent pneumococcal nontypeable Haemophilus Influenzae protein conjugate vaccine &#40;PCV-10&#41; manufactured by GlaxoSmithKline in 2010&#46; In January 2016 the immunization schedule was changed from 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 to 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1&#46; The IPD rate in the post-PCV-10 period in children under 18 year of age was 5&#46;5&#47;100&#44;000&#47;year&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> The World Health Organization estimated the national immunization coverage in Brazil over 80&#37; of the PCV-10&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">After the first decade of introduction of the PCV-10 in Brazil&#44; the analysis between two immunization schedules and occurrence of IPD became relevant&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design</span><p id="par0020" class="elsevierStylePara elsevierViewall">A retrospective cohort study evaluating incidence&#44; general characteristics and in-hospital clinical outcomes for pneumococcal infections&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Setting</span><p id="par0025" class="elsevierStylePara elsevierViewall">The study was performed in a public-affiliated tertiary-care facility&#46; It offers acute care for a direct population of 600&#44;000 inhabitants and a reference of 1&#46;4 million inhabitants&#44; admitting only patients referred by primary and secondary-care services or by ambulances&#46; All patients under 18 years old admitted to the study facility from January 1&#44; 2010 to December 31&#44; 2019 were considered potentially eligible to be included in the study if they had a microbiologically confirmed IPD&#46; We analyzed only community-associated infections&#46; Patients could be included more than once if they had two episodes of infection at least one month apart&#46; Were excluded episodes of colonization or asymptomatic infection&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Data collection</span><p id="par0030" class="elsevierStylePara elsevierViewall">Our departure was the microbiological laboratory data bank&#46; We searched the genus&#47;species identification and corresponding susceptibility test&#44; both performed automatically by the Vitek 2 system&#44; and confirmed by referential laboratory&#44; Adolfo Luzt by PCR for serotype identification and susceptibility test by E-test&#46; Demographic and clinical data were collected from the patient&#39;s medical records previously approved by the human research ethics committee&#40;n&#176; CAAE 20076819&#46;2&#46;0000&#46;5440&#41;&#46; All isolates were divided in two groups&#44; the first group was defined in the period with the PCV-10 immunization schedule 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 corresponding to the years 2010-2015 and the second in the period with the schedule 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 corresponding to the years 2016&#8211;2019 according to the immunization change in the Brazilian&#39;s national immunization program&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Data analysis</span><p id="par0035" class="elsevierStylePara elsevierViewall">First we analyzed the temporal global incidence of infections related to each one of the two immunization schedules of PCV-10 over the study period&#46; Finally&#44; we compared all the patients included regarding clinical presentation and in-hospital outcome&#46; Sepsis was considered by pediatric adjusted SOFA score and septic shock by use of vasoconstrictor agents&#46; The global mortality rate was considered for patients that died in the 30 days prior to diagnosis&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Statistical analysis</span><p id="par0040" class="elsevierStylePara elsevierViewall">For calculating the incidence risk ratio &#40;IRR&#41; by group we used R program 3&#46;6&#46;1&#46; To associate immunization schedule with strategic outcomes of interest&#44; simple and multiple log-binomial regression models were fitted&#44; resulting in raw and adjusted risk estimates&#44; considering age&#44; vaccination history&#44; sensitivity to penicillin and ceftriaxone as covariates&#46; We used the statistical software SAS 9&#46;4&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">From the initially screened 211 cultures&#44; 135 were excluded for age<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>18 years and 14 were excluded because of duplication or due to patients not meeting clinical criteria for infection&#44; 2 patients were included twice&#46; The mean age of patients was 13&#46;15 months&#44; for group 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 was 11&#46;08 months and for group 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 was 18&#46;86 months&#44; 58&#37; of patients were male and 67&#37; had a completed schedule for PCV-10&#46; Therefore&#44; 62 infection episodes were included in the study&#46; 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 accounted for 61&#46;3&#37;&#40;38&#47;62&#41; of the immunization schedule in 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 period&#44; and 38&#46;7&#37;&#40;24&#47;62&#41; of the immunization schedule in 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 period&#44; respectively&#46; The most common diagnosis was pneumonia in both periods and meningitis was more common in the 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 period than in the 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 period as shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> exhibits the incidence density rate per 1000 patients admissions in the facility during the study period divided by age&#46; The incidence density rose in 2011 after PCV-10 introduction and again in 2018 after the schedule change&#44; however&#44; remains equal in both periods used IRR by person-year with a <span class="elsevierStyleItalic">p</span> value 0&#46;89 &#40;95&#37; CI&#58; 0&#46;58&#8211;1&#46;61&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">In the results&#44; 14 pneumococcal serotypes were isolated in 50 samples of positive cultures &#40;80&#44;6&#37;&#41;&#44; with 19A being the most frequent &#40;25&#46;8&#37;&#41;&#44; followed by serotype 3&#40;11&#46;3&#37;&#41;&#44; 6A&#40;8&#46;1&#37;&#41; and 6C&#40;8&#46;1&#37;&#41;&#46; In 12&#40;19&#46;4&#37;&#41; of the 62 positive samples&#44; serotype was not identified for technical reasons&#46; In the 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 group the serotype 19A had the highest absolute value&#40;ten samples&#41; and percentage &#40;41&#46;6&#37;&#41; in relation to all other serotypes when compared with the 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 group&#44; six samples &#40;15&#46;8&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">We observe that six &#40;7&#46;1&#37;&#41; of the samples showed resistance to penicillin and seven &#40;11&#46;3&#37;&#41; intermediate resistance&#46; For ceftriaxone&#44; we found four &#40;6&#46;4&#37;&#41; isolated with intermediate resistance and no sample with full resistance&#46; For levofloxacin&#47;ciprofloxacin and vancomycin there was no resistance&#46; The highest percentage of resistance &#40;52&#46;7&#37;&#41; resulted for the antibiotic sulfamethoxazole&#47;trimethoprim&#46; Moreover&#44; we saw a slight decrease in the penicillin resistance from 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 group&#44; 2 samples &#40;3&#46;2&#37;&#41; compared to 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 group&#44; 4 samples &#40;6&#46;4&#37;&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The outcomes tested were sepsis with RRa &#40;adjusted relative risk&#41; &#40;CI 95&#37;&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;77 &#40;0&#46;28&#59;27&#46;42&#41;&#44; septic shock RRa &#40;CI 95&#37;&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;34 &#40;0&#46;10&#59;1&#46;11&#41;&#44; chest drain open or closed RRa &#40;CI 95&#37;&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;08 &#40;0&#46;43&#59;2&#46;66&#41;&#44; complicated pneumonia&#44; RRa &#40;CI 95&#37;&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;05 &#40;0&#46;10&#59;11&#46;29&#41;&#44; dead&#44; RRa &#40;CI 95&#37;&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;05 &#40;0&#46;10&#59;11&#46;29&#41;&#44; without difference in both schedule&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Besides that&#44; we tested other outcomes such as antibiotic &#40;days&#41;&#44; chest drain &#40;days&#41;&#44; length of stay in the Intensive Care Unit &#40;ICU&#41; &#40;days&#41;&#44; length of stay &#40;days&#41; and mechanical ventilation &#40;days&#41;&#46; Regarding the survival curves&#44; the only that showed a difference was the length of stay in the ICU&#44; the raw hazard ratio was 2&#46;46 CI 95&#37; &#40;0&#46;93&#59;6&#46;48&#41; and the adjusted was 2&#46;52&#44; CI 95&#37; &#40;0&#46;82&#59;7&#46;81&#41; like we highlighted in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The global mortality rate was 8&#37;&#44; 3 patients had meningitis&#44; 1 had pneumonia and 1 had occult bacteremia&#44; 4 of them didn&#8217;t have any comorbidity&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">After the introduction of PCV-10 in Brazil&#44; several authors have conducted studies with the purpose of evaluating its impact on morbidity&#44; using the hospitalization rate for pneumonia&#44; and on mortality from IPD in children&#44; with a significant decrease after the introduction of the vaccine&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;3&#8211;5</span></a> Regarding the incidence rates&#44; despite an increase in the number of IPD cases in 2011 and 2018 in this analysis&#44; we did not find any difference in both periods analyzed as observed in literature&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> However&#44; it is not possible to state that the referred result is a trend&#44; due to continuing the evaluation of the historical series studied&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Our results demonstrate a change in serotype profile&#44; with low percentage values of serotypes included in PCV-10&#46; There was a predominance of serotype 19A&#44; found in PCV-13&#46; In a prior analysis in this hospital it was observed that the most common serotype in children under 5 years and the third most common serotype between 5 and 20 years was the serotype 14&#44; included in PCV-10&#46; The 19A was corresponding just to 5&#46;9&#37; of children under 5 years&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> This may highlight a serotype replacement&#44; same as in literature&#46;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5&#44;8&#44;9</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Regarding antimicrobial profile&#44; we found 8&#37; of cultures studied resistant to penicillin and a slight decrease in 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 group&#46; This result is conflicting when compared to other geographical regions worldwide&#44; in which pneumococcal resistance to penicillin occurs on a larger scale&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> However&#44; other researchers have seen the same antimicrobial profile in our country&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">11&#8211;13</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">In some countries the immunogenicity and effectiveness of 3 doses in IPD has been demonstrated despite the 4 recommended doses&#44;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6&#44;14&#44;15</span></a> resulting in a change in recommendations to 3 doses in countries like Brazil&#46; The outcome of sepsis&#44; septic shock&#44; chest drain open or closed&#44; complicated pneumonia and death&#44; did not show any difference in the two immunization schedules&#46; When other variables were analyzed&#44; the only that showed a difference was the length of stay in the ICU&#46; These differences may be due to improving assistance care outside and inside the hospital&#46; However&#44; other research shows the same effectiveness for different schedules<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> in IPD&#44; the previous study did not analyze the clinical outcomes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The present study has some limitations like the lack of originality&#44; the limitations of the study &#40;small sample&#44; short-follow up time&#44; possible inconsistencies in the collected information due to the retrospective nature of the study&#41; and the obtained results&#44; which are inconclusive&#46; Furthermore&#44; It is important to carry out more complete studies to get more robust conclusions on this topic&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In conclusion&#44; two immunization schedules of PCV-10 show an equal performance in our service&#46; Our results may highlight a serotype replacement without worse outcomes&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Authors&#8217; contribution</span><p id="par0110" class="elsevierStylePara elsevierViewall">All authors have participated in &#40;a&#41; conception and design&#44; or analysis and interpretation of the data&#59; &#40;b&#41; drafting the article or revising it critically for important intellectual content&#59; and &#40;c&#41; approval of the final version&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Funding</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interests</span><p id="par0120" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">10-Valent pneumococcal conjugate vaccine &#40;PCV-10&#41; is the immunization routine in Brazil since 2010&#46; In 2016&#44; the immunization schedules changed from 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 to 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 doses for children in the first year of age&#46; The analysis of the relationship with the occurrence of invasive pneumococcal disease &#40;IPD&#41; in the different schedule vaccine period becomes relevant&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective cohort study evaluating the incidence&#44; general characteristics and in-hospital clinical outcomes for invasive pneumococcal infections&#46; We included community-associated infections by microbiological laboratory tests from 2010 to 2019&#46; According to the immunization schedule&#44; we divided the groups in 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 and 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1&#46; We collected clinical data from medical records&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We identified 62 cases of pneumococcal infections &#40;3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#44; 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41;&#46; Overall&#44; the incidence density in the two immunization schedules remains equal&#46; The most common serotype was 19A&#46; The outcomes of sepsis&#44; septic shock&#44; chest drain open or closed&#44; complicated pneumonia and death&#44; did not show any difference in the two schedules&#46; Regarding the survival curves&#44; the only one that would apply a proportional risk model &#40;the curves do not intersect&#41;&#44; is related to the length of stay in the ICU&#46; In this case&#44; the raw hazard ratio was 2&#46;46 95&#37; CI &#40;0&#46;93&#59; 6&#46;48&#41; and the adjusted was 2&#46;52&#44; 95&#37; CI &#40;0&#46;82&#59; 7&#46;81&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The two immunization schedules of PVC-10 show an equal performance in our service&#46; Our results may highlight a serotype replacement with no worse outcomes&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La vacuna conjugada antineumoc&#243;cica 10-valente &#40;PCV-10&#41; es la rutina de inmunizaci&#243;n en Brasil desde 2010&#46; En 2016&#44; el calendario de vacunaci&#243;n cambi&#243; de dosis de 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 para 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 en ni&#241;os en el primer a&#241;o de edad&#46; Es de importante relevancia el an&#225;lisis de la relaci&#243;n de la enfermedad neumoc&#243;cica invasiva en los diferentes esquemas de vacunaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Este fue un estudio de cohorte retrospectivo que evalu&#243; la incidencia&#44; las caracter&#237;sticas generales y los resultados cl&#237;nicos hospitalarios de las infecciones neumoc&#243;cicas invasivas&#46; Incluimos infecciones asociadas a la comunidad mediante pruebas de laboratorio microbiol&#243;gicas del 2010 al 2019&#46; De acuerdo con el calendario de vacunaci&#243;n&#44; dividimos los grupos en 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1 y 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1&#46; Recolectamos datos cl&#237;nicos de historias cl&#237;nicas&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Identificamos 62 casos de infecciones neumoc&#243;cicas &#40;3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>38&#44; 2<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>1<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>24&#41;&#46; En general&#44; la densidad de incidencia en los 2 calendarios de vacunaci&#243;n continu&#243; siendo la misma&#46; El serotipo m&#225;s com&#250;n fue el 19A&#46; Los resultados de sepsis&#44; shock s&#233;ptico&#44; drenaje tor&#225;cico abierto o cerrado&#44; neumon&#237;a complicada y muerte no mostraron ninguna diferencia en los 2 calendarios&#46; En cuanto a las curvas de supervivencia&#44; la &#250;nica que aplicar&#237;a un modelo de riesgo proporcional &#40;las curvas no se cruzan&#41; est&#225; relacionada con el tiempo de estancia en la UCI&#46; En este caso&#44; la raz&#243;n de riesgo bruta fue 2&#44;46 &#40;IC del 95&#37;&#44; 0&#44;93&#59; 6&#44;48&#41; y el ajustado fue 2&#44;52 &#40;IC del 95&#37;&#44; 0&#44;82&#59;7&#44;81&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los 2 esquemas de vacunaci&#243;n de PVC-10 muestran un desempe&#241;o igual en nuestro servicio&#46; Nuestros resultados pueden destacar un reemplazo de serotipos sin resultados desfavorables&#46;</p></span>"
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                      "autores" => array:1 [
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                          "autores" => array:6 [
                            0 => "A&#46; Andrade"
                            1 => "R&#46; Minamisava"
                            2 => "G&#46; Policena"
                            3 => "E&#46; Cristo"
                            4 => "C&#46; Domingues"
                            5 => "M&#46; de Cunto Brandileone"
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                        "tituloSerie" => "Hum Vacc Immunotherap"
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                        "volumen" => "12"
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